Phia GroupPhia Group Mediahttps://phiagroup.com/Media/PostsAutism Benefits: DOL Enforcement for Sufficient Coveragehttps://phiagroup.com/Media/Posts/PostId/1247/autism-benefits-dol-enforcement-for-sufficient-coverageBlog,DOLMon, 22 May 2023 14:35:42 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Kaitlyn Malkin, Esq. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">About 1 in 36 children in the United States has autism spectrum disorder, which is a lifelong condition that can affect a person’s behavior, communication, interactions, and ability to learn. The Department of Labor (DOL) continues strongly advocating for more comprehensive autism coverage under group health plans and Employee Benefits Security Administration (EBSA) has been working to ensure individuals who need treatment are able to access it. The Phia Group is also working hard to ensure plans are offering robust benefits while remaining compliant with mental health parity laws.  </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The main mechanism that EBSA is using to ensure adequate access is reliance on the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires group health plans that offer mental health benefits to have financial requirements and nonquantitative treatment limitations in parity, meaning that any limitation on mental health or substance use disorder benefits contained in the plan is no more restrictive than those applied to medical or surgical benefits. For autism spectrum disorder, these restrictions can range from age limitations to weekly or annual intervention limits. Autism coverage is typically offered as part of a plan’s mental health benefits; therefore such benefits are protected under the MHPAEA. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The EBSA office in Los Angeles recently investigated a large service provider that systematically excluded coverage for ABA therapy, the primary treatment for autism, in hundreds of self-funded plans and found that this exclusion was out of parity. These plans have removed their exclusion for ABA therapy and will now be offering coverage for their participants and beneficiaries. EBSA also regularly works with the Department of Health and Human Services and other agencies to investigate denials of coverage for autism treatment. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The Phia Group’s consulting and NQTL teams, through our consulting umbrella, regularly review issues related to mental health benefit offerings and recommend changes to benefits coverage to ensure that mental health coverage is provided in compliance with the MHPAEA.</span></span></span></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">We recommend that all group health plans that provide mental health benefits and are subject to the MHPAEA review their SPDs for compliance with the mental health parity rules. We are here to help if you are not sure where to start. Reach out to our team at <a href="mailto:Phia-NQTL@PhiaGroup.com" style="color:#0563c1; text-decoration:underline">Phia-NQTL@PhiaGroup.com</a> for more information on our mental health compliance work.</span></span></span></p> 1247New Year, New Rules – But Don’t Forget About the Old Oneshttps://phiagroup.com/Media/Posts/PostId/1210/new-year-new-rules-but-dont-forget-about-the-old-onesBlog,Affordable Care Act,DOLTue, 03 Jan 2023 13:11:26 GMT<p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">By: Kelly E. Dempsey, Esq. </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The self-funded health plan industry continues to evolve every year based on new rules, guidance, and medical advancements; however, the Department of Labor (DOL) doesn’t overlook old rules either. In case you missed it, there was a case in mid-2022 that seeks to remind us that the DOL is still considering all Affordable Care Act (ACA) rules when they review complaints and perform audits. In <em><span style="font-family:"Calibri",sans-serif">Walsh v. Board of Trustees of Local 272 Welfare Fund and Local 272 Welfare Fund, 22-cv-592 (S.D.N.Y August 2, 2022)</span></em><em><span style="font-family:"Calibri",sans-serif"><span style="font-style:normal">, the DOL filed suit against a Taft-Hartley welfare plan and its trustees for alleged violations of certain amendments that the ACA made to ERISA, including the maintenance of grandfathered status.<br /> <br /> It’s always been my personal opinion that the regulation writers, government entities, and various departments assumed that health plans would be unable to maintain grandfathered status much past 2014 based on the way the rules were written and exceptions for grandfathered plans effectively ending in 2014. I believe their thought process is that grandfathered status would end within a few years after 2010 because the plans would need to make adjustments for financial solvency and in response to the ever-changing insurance market and employee population demands.<br /> <br /> There are many plans that continue to present themselves as grandfathered as we start 2023 and I would challenge those plans to do some self-reflection (and a large amount of math) to confirm grandfathered status has been maintained. The </span></span></em><em><span style="font-family:"Calibri",sans-serif">Walsh</span></em><em><span style="font-family:"Calibri",sans-serif"><span style="font-style:normal"> case is an important example of why it’s important to review grandfathered status and confirm it has been maintained over the last 12 years. In </span></span></em><em><span style="font-family:"Calibri",sans-serif">Walsh</span></em><em><span style="font-family:"Calibri",sans-serif"><span style="font-style:normal">, it was found that the plan had made changes to member out-of-pocket obligations over the course of time that caused a loss in grandfathered status and had effectively held itself out to be grandfathered for an additional 8 years in error. The plan and the DOL negotiated and reached an agreement. The plan agreed to several plan changes, to notify participants of the non-compliance, reprocess claims incurred since 2019 for participants that took action based on the notice letters, and to report to the DOL every six months for two years regarding the number of participants that sought relief under the settlement. </span></span></em></span></span><br /> <br /> <em><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="font-style:normal">For those plans that still purport to be grandfathered, it’s important to be able to provide documentation that grandfathered status is maintained over the last 12 years. If you’re uncertain what changes cause a loss in grandfathered status, Phia can certainly assist with an overview of the rules. It’s also important to remember that the DOL is actively reviewing participant complaints and performing audits of all different types. One type of audit can always lead to a bigger audit – we’ve seen it happen – so make sure to continuously review your plans for compliance, including compliance with all those old rules that are still in effect.</span></span></span></em></p> 1210The Fair Labor Standards Act (FLSA): Who Benefits and Who Doesn’thttps://phiagroup.com/Media/Posts/PostId/1196/the-fair-labor-standards-act-flsa-who-benefits-and-who-doesntBlog,DOL,Health Insurance,Healthcare CostsFri, 04 Nov 2022 13:41:00 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">It’s hard to fathom today, but less than a century ago, America was a country in which elementary-school-aged children were accustomed to laboring in coalmines, glass factories, and shipyards; an untold number of employees earned less than $1 <i>per day</i>; a typical workweek consisted of six 12-hour shifts. Such was life for tens of millions of Americans barely scraping by during the depths of the Great Depression before FDR implemented his landmark New Deal, which, among other initiatives, provided workers greater protection with the passage of the Fair Labor Standards Act (FLSA). </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></span></span></p> <h2>Fair Labor Standards Act for Independent Contractors</h2> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">Although the FLSA, signed into law on June 25, 1938, did safeguard future generations of Americans from the perils of unfettered capitalism, the statute has not remained immutable for the past eighty-four years. At its core, the FLSA entitles American workers to a minimum wage and overtime pay. Contracted workers, that is. Independent contractors, in contrast, are not entitled to such rights. Unsurprisingly, there has been great ambiguity concerning the differentiation between an independent contractor and employee, particularly amidst the recent presidential transition.</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></span></span></p> <h2>New FLSA Proposal in 2021</h2> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">Under the Trump administration in January 2021, a rule was passed that focused on two core factors (control over the work and opportunity for profit or loss) in determining the classification of an independent contractor. Some believed that this rule enabled employers to misclassify their workers as “freelance contractors” in order to eschew regulations leading to higher payroll taxes and benefit expenses. Last month, the U.S. Department of Labor (DOL), behind the strong backing of the Biden administration, did in fact issue a proposed rule change to lower the threshold for who can be deemed an employee. (This is the DOL’s second attempt to amend the law after its 2021 proposal was denied by a federal court.) The underlying goal of the proposal is to help millions of American employees working in a gig economy (i.e., janitorial employees, construction workers, Uber drivers) reap the benefits of the FLSA, namely minimum wage protection, overtime pay, paid leave, and perhaps even health benefits. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></span></span></p> <h2>What the new FLSA Proposal Entails</h2> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">So, what exactly does the new proposal entail? In an effort to ensure that no one factor has a predominant influence, the following six-factor economic reality test was presented as a means of identifying whether an employee is economically dependent on their employer: </span></span></span></span></span></span></span></p> <ol> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Opportunity for profit or loss depending on managerial skill; </span></span></span></span></span></span></span></span></li> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Investments by the worker and the employer; </span></span></span></span></span></span></span></span></li> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Degree of permanence of the work relationship; </span></span></span></span></span></span></span></span></li> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Nature and degree of control; </span></span></span></span></span></span></span></span></li> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Extent to which the work performed is an integral part of the employer’s business; and </span></span></span></span></span></span></span></span></li> <li style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="background:white"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="letter-spacing:.4pt">Skill and initiative. </span></span></span></span></span></span></span></span></li> </ol> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">If this newly proposed rule is finalized, and that will not be known until later this year, it would essentially reinstate the “traditional” economic realities test previously used under the auspices of the FLSA. While many in the Biden administration are in support of reinstatement, there is a sizable contingent of detractors who fear that an expanded set of factors will leave businesses rudderless in their attempts to classify employees. </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">Though some industries will remain unaffected by the forthcoming decision, many that depend on independent contractors to operate their respective businesses, most notably construction, trucking, and ridesharing, are closely monitoring this issue of worker classification, one that could leave them facing new legal liabilities.</span></span></span></span></p> 1196